The language of CTO interventions

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The language of CTO interventions what it all
means

• Dr Angela Hoye
• Senior Lecturer in Cardiology
• Hull East Yorkshire Hospitals

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MY CONFLICTS OF INTEREST ARE Clinical Events
Committee member for SPIRIT II, SPIRIT V and
SPIRIT Woman, fees paid by Abbott Vascular Inc
and a CTO enthusiast..............
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Why do we open CTOs?
Quality of life
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• Explosion of interest!

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• Try to explain/simplify some of the language used
  during CTO angioplasty
• Discuss the design and use of some of the
  specialised devices
• Focus on the techniques
• antegrade
• retrograde

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• Know when (and how) to use the right device in
  what circumstance
• Specialist wires
• Hydrophilic eg Whisper, Fielder FC
• Stiff tip eg Miracle family
• Tapered tip eg Fielder XT, Confianza
• Tip load

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Tip load Weight needed to be applied to bend /
buckle the tip of the guide wire
Floppy lt1g Intermediate 3g Stiff 4.5g
Stiff wires especially when combined with a
tapered tip increase penetration power but also
increase the risk of perforation
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• Examples

Wire Tip load (g) Size of tip
Fielder FC 1.6 0.014
Fielder XT 1.2 0.009
Miracle 6 6 0.014
Confianza 9 8.6 0.009
Confianza Pro 9 9.3 0.009
Confianza Pro 12 12.4 0.009
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• TORNUS (Abbott Vascular)
• Braided stainless steel flexible catheter able to
  enlarge the vessel by screwing through it
• Tapered tip
• Rotate counter-clockwise to advance
• Clockwise to withdraw
• No more than 10-20 rotations in the same
  direction

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Corsair (Vascular Perspectives)

• Tapered soft tip
• Hydrophilic coating
• ASAHI brand braiding pattern, consisting of 8
  thinner wires wound with 2 larger ones
• Advancement
• hold a torque device at all times to avoid ASAHI
  Corsair and the guide wire to be rotated together
• Image the Corsair tip under fluoroscopy to make
  sure that the tip is not trapped by the lesion
• avoid torque accumulation - limit the rotation to
  10 times in one direction. To continue advancing
  ASAHI Corsair, rotate the opposite direction
• Rotate the Corsair during removal into the guide

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• Wiring techniques (antegrade approach)
• ? Parallel wires / seesaw

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Mitsudo et al J Inv Cardiol 2008
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• Eg. Balloon support, parallel wire technique, use
  of simultaneous coronary injection

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• Anchor balloon
• Used when need more penetration power and the
  guide catheter is backing out

Fujita et al Catheterization and Cardiovascular
Interventions 59482488 (2003)
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Fujita et al Catheterization and Cardiovascular
Interventions 59482488 (2003)
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• STAR subintimal tracking and re-entry

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• STAR
• Create a (long) dissection plane with a
  hydrophilic wire eg Whisper or Pilot with an
  umbrella handle tip
• Advance the wire whilst maintaining the loop
• 1.5mm OTW balloon for support
• Best suited to the RCA with few proximal branches

Colombo et al CCI 200564407-11
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Case example
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• STAR results of 68 patients
• Procedural success in 62
• Dissection limiting procedure in 6
• Perforation in 7 (limited the procedure in 4)
• Pericardial effusion in 7 though no
  pericardiocentesis
• At follow-up restenosis in 45
• TLR 29 after DES
• TLR 50 after BMS
• Last resort

Carlino et al Catheterization and Cardiovascular
Interventions 72790796 (2008)
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• What about backwards?
• Kissing wires
• CART
• Reverse CART
• Knuckle wire technique
• rendezvous
• etc etc.................

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• Principle of the retrograde technique

Antegrade wire
Retrograde wire
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• Principles of the retrograde technique
• Short (80-85cm guide), typically 7F
• Hydrophilic wire through the collateral
• Septal collaterals are preferable to epicardial
  ones
• Choose collaterals that are straight
• Good filling of the distal vessel from a
  selective injection into the collateral is ideal
  though not essential
• Collateral dilatation low pressure (1-2atm)
  dilation with a very small balloon (lt1.5mm) or
  use the Corsair

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• Kissing wires

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• What about the CART technique?

controlled antegrade and retrograde subintimal
tracking
Surmely et al J Invasive Cardiology 2006
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• CART
• Simultaneous antegrade and retrograde approach
• Create a (localised) subintimal dissection by
  inflating a small (1.5-2.0mm balloon) over the
  retrograde wire

Surmely et al J Invasive Cardiology 2006
Surmely et al J Invasive Card 200618334338
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• The balloon is kept in place to keep the
  subintimal space open
• The antegrade wire is advanced further along the
  deflated retrograde balloon that lies from the
  subintimal space to the distal true lumen
• Dilatation and stent implantation in the usual
  manner

Surmely et al J Invasive Card 200618334338
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• CART
• localised dissection

STAR long dissection
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Reverse CART
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Surmely et al J Invasive Cardiology 2006 Rathore
et al J Am Coll Cardiol Intv 20103155 64
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• Knuckle wire

Galassi et al Clin Res Cardiol (2010) 99587590
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• Rendezvous in coronary technique

Muramatsu et al J Invas Cardiol 2010
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• Rendezvous in coronary technique

Muramatsu et al J Invas Cardiol 2010
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• Rendezvous in coronary technique

Muramatsu et al J Invas Cardiol 2010
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• Rendezvous in coronary technique

Muramatsu et al J Invas Cardiol 2010
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• Reverse anchoring technique

Matsumi et al Catheterization and Cardiovascular
Interventions 71810814 (2008)
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• IVUS
• All these techniques can be facilitated with
  adjunctive IVUS
• Help identify the entry point into the occlusion
• Help direct a stiff wire to penetrate from the
  sub-intima back into the true lumen
• Guide and optimise the result of stenting

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• Summary Conclusions
• Recent advances in CTO angioplasty have increased
  the rate of successful recanalization
• In contemporary practice CTO PCI involves a range
  of specialised devices
• Specialist techniques may involve both an
  antegrade and retrograde approach with the aim of
  passing the wire from the proximal to the distal
  true vessel lumen
• In expert hands, these techniques have a good
  success rate (and low complication rate)

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Thankyou!
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